The jury's still out on hospitalists

Our Reader Poll: The jury's still out on hospitalists

By Neil Chesanow, Senior Editor

Even primary care doctors who willingly use inpatient specialistssee some drawbacks, our informal survey reveals.

Are hospitalists a bane or a blessing? We polled Medical Economicsreaders on that issue--certainly one of the hottest in medicine today.

Faxed responses came from 147 doctors, the vast majority of them FPsand internists. The findings aren't scientific, by any means. But they presenta revealing--and occasionally surprising--snapshot of how primary care doctorsfeel about giving up inpatient practice.

More than half of the family doctors and more than one-third of the internistswho responded said they refer patients to hospitalists. Most said they doso voluntarily.

Many of those respondents who refuse to turn over patients to hospitalistsfeel strongly about their stand. "Hospitalists represent divisive,bottom-line medicine and fragmented, lousy care, without continuity or humaneinvolvement with patients," a solo Florida FP fumed. A North CarolinaFP cast the issue in moral terms. "Abandoning my patients when theyare sickest and most vulnerable would be completely counter to what a primarycare physician should do," he wrote.

For many of these doctors, hospital practice is an inseparable part ofbeing a physician. "I left Germany in 1954 because I couldn't treatmy patients once they were referred to the hospital," wrote a Wisconsininternist in a 15-doctor multispecialty group. A Florida internist declared:"I became a doctor to care for sick patients. You can keep the office.I didn't go to school my whole life to care for colds, sore throats, andhypochondriacs!"

A number of respondents were adamant that hospital practice shouldn'tbe only an option. "Without treating patients in the hospital, doctorswill eventually lose their ability to recognize and treat complicated problemsand will become nurse practitioners," concluded a member of a groupof 10 internists in Boston. "I'm sure doctors who refer to hospitalistsare already little more than that."

Asserted a Utah FP in a six-doctor practice: "It's clear that hospitalistswill cause a decrease in primary care skills and education. What's not clearis whether they will decrease costs or improve care."

Even doctors who endorse the concept of hospitalists often seem ambivalentabout using them. More than two thirds of the FPs and GPs and more than75 percent of the internists are concerned that if they hand off patientsto hospitalists their clinical skills will deteriorate.

A New York state FP in a 120-doctor multispecialty group fretted, "Bygiving up hospital practice, doctors face the fact that the differentiationbetween primary care physicians and midlevel providers is becoming dangerouslynarrow."

In our minipoll, about 50 percent of FPs and GPs, and about 60 percentof internists, responded that the prospect of surrendering inpatient practicemade them feel like a less complete physician. But a Pennsylvania FP feltsuch fears are misplaced. "Many primary care physicians overrate theirinpatient skills," he wrote. "The ability to recognize our shortcomingsbenefits our patients."

Half of the respondents warned that using hospitalists will erode thebond between patients and primary care doctors. An Ohio FP, whose multispecialtygroup uses hospitalists, conceded, "Unfortunately, business in medicinenow outweighs the social benefits of traditional doctor-patient relationships."

Equal numbers of FPs and internists say they are required to refer patientsto hospitalists. About half of the polled doctors who use hospitalists involuntarilyare soloists or practice in groups of two to four physicians. That suggeststhe mandate came either from their IPA or a major health plan. Most of theothers are in large multispecialty practices, where it's probable that thegroup itself made hospitalist use mandatory.

Even without a hospitalist mandate, some primary doctors feel financialpressure to turn over their inpatients. A California FP wrote: "Inour 60-doctor group, nonhospitalists can admit, but our income is reducedto pay for the service even if we don't use it."

Surprisingly, nearly all respondents who use hospitalists--by mandateor by their own choice--described the care rendered by inpatient specialistsin favorable terms. In fact, only one poll participant rated it as deficient.That doctor, a solo internist in California, characterized hospitalistsas "physicians who failed in private practice, so they continue tofare poorly, with poor clinical communication overall."

But virtually every other respondent who uses hospitalists, willinglyor not, sees one distinct advantage: It gives them more time in the office--andat home. "I've cut my work hours from 80 or more a week to an 8-to-5schedule five days a week," an internist in a two-doctor practice exulted."And my income has actually increased!" A solo internist in NewYork state acknowledged, "Like it or not, we simply can't be availableto our patients more than eight hours a day without constant disruptionof our family lives."

Other primary care physicians in our poll emphasized the upside of theirrelations with hospitalists. "The hospitalists in our group fax alladmission histories and physicals--as well as progress reports and dischargeinstructions--to each primary care physician each day," wrote a Louisianainternist in a 75-doctor multispecialty practice.

"Having hospitalists available has lifted the dread and vulnerabilityI felt whenever my beeper went off," an Ohio FP noted. "Now Ican relax when I'm at home." Another doctor commented: "The hospitalistsI use are caring, competent, give feedback, and send good summaries. Mypersonal life is better, my office runs a lot better, and I'm busier inmy office than I've ever been. There's a lot less stress and wasted traveltime."

We had expected some complaints from doctors who use hospitalists aboutcontinuity of care and communication. Surprise: There were almost none.Instead, praise was prevalent among the poll responses. An Alabama GP ina two-doctor practice, for instance, lauded hospitalists for keeping himin the loop. "I have more contact with my patients using hospitalistsat an acute care hospital 50 miles away than I do at my local hospital,where specialists fail to communicate with me about my patients," hewrote.

So what's the message from our informal poll about hospitalists? Primarycare doctors are split into opposing camps, and there are strong opinionspro and con. Even so, the overwhelmingly positive comments of physicianswho actually use hospitalists are notable.

A Philadelphia practitioner's enthusiasm is typical: "Since I'vebeen using hospitalists, patient care is much improved and more efficientlycarried out, and my quality of life is far superior to what it used to be,"that doctor wrote. "It's wonderful!"

The impact of hospitalists? Here's what readers say

To what degree do you agree or disagree with the following statements:

Because of rounding, perc entages don't always add to 100. Source: MedicalEconomics' Reader Fax Poll on Hospitalists



Neil Chesanow. The jury's still out on hospitalists. Medical Economics 1999;18:115.